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psnet.ahrq.gov/node/42178/psn-pdf
April 10, 2013 - These high stakes have led many
institutions to routinely require outside case review prior to treatment
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psnet.ahrq.gov/node/36907/psn-pdf
September 14, 2012 - When such an event occurs,
many institutions mandate performance of a root cause analysis.
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psnet.ahrq.gov/node/43258/psn-pdf
May 01, 2015 - The Joint Commission and the Accreditation Council for Graduate Medical Education have
called for institutions
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psnet.ahrq.gov/node/45715/psn-pdf
November 01, 2017 - In this mixed methods analysis, executive walk rounds were implemented across six long-term
care institutions
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psnet.ahrq.gov/issue/second-trial
November 08, 2017 - program-generated data will inform site specific toolkits and change implementation support for participating institutions
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psnet.ahrq.gov/issue/disclosing-adverse-events-patients-international-norms-and-trends
July 29, 2020 - safety culture , and establishment of standard metrics to document and benchmark disclosure across institutions
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psnet.ahrq.gov/issue/anti-black-racism-chronic-condition
December 17, 2020 - This commentary discusses the relationship between medical ethics and racism in healthcare institutions
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psnet.ahrq.gov/issue/graduate-medical-educations-new-focus-resident-engagement-quality-and-safety-will-it
July 14, 2021 - Clinical Learning Environment Review (CLER) program was developed to evaluate the performance of teaching institutions
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psnet.ahrq.gov/issue/continuous-improvement-ideal-health-care
August 04, 2021 - outlines a number of critical steps for implementation, including committing resources, organizing within institutions
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psnet.ahrq.gov/issue/expert-consensus-currently-accepted-measures-harm
January 25, 2023 - A panel of 71 experts from nine institutions identified 218 triggers and measures with high or very high
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psnet.ahrq.gov/issue/i-pass-mentored-implementation-handoff-curriculum-champion-training-materials
November 16, 2022 - by participants as instrumental in the success of leading staff to adopt I-PASS techniques at the institutions
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psnet.ahrq.gov/web-mm/risks-absent-interoperability-medication-induced-hemolysis-patient-known-allergy
April 08, 2019 - List two key barriers to incorporation and reconciliation of information transmitted between institutions … are the main barriers to achieving interoperability across information technology systems and across institutions … to facilitate the transmission of patient information instantly and seamlessly between health care institutions … The HITECH Act requires current health IT systems and health care institutions to be able to rapidly … barriers to rapid and seamless transmission of patient care data include financial incentives that prevent institutions
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psnet.ahrq.gov/web-mm/right-patient-wrong-sample
June 01, 2004 - associated with better performance.( 5,7 ) For example, a Q probes study of critical value reporting in 623 institutions … For example, a study of wristband errors from 217 institutions showed that the wristband error rate in … participating institutions decreased from 7% to 3% over the 2 years of study.( 9 ) The most common error … College of American Pathologists Q-Probes study of patient and specimen identification errors at 120 institutions … Laboratory critical values policies and procedures: a College of American Pathologists Q-Probes study in 623 institutions
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psnet.ahrq.gov/node/49553/psn-pdf
January 01, 2008 - The value of multiple cultures
largely flows from probability considerations: Most institutions have … Reducing Contamination
We cannot eliminate blood culture contamination entirely, but it is possible for institutions … Because approximately half of all positive blood cultures in most institutions represent contamination … Blood culture contamination is common, constituting up to half of all positive blood cultures at some
institutions … Institutions can reduce blood culture contamination by using the most effective antiseptic agents and
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psnet.ahrq.gov/node/33766/psn-pdf
May 01, 2014 - In most institutions, it is best to begin with an
aggregated approach. … http://www.ncbi.nlm.nih.gov/pubmed/24581011
http://www.ncbi.nlm.nih.gov/pubmed/23453174
In most institutions … practices, to their
own language, but also to the culture and to the way people are working in their own institutions … DP: As you may understand, I've been confronted with this discussion before and have visited some
institutions … I have visited too many institutions
where the institution is not providing the tools for people to
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psnet.ahrq.gov/node/40309/psn-pdf
April 22, 2011 - implementation of safety practices and increase
the generalizability of successful strategies for other institutions
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psnet.ahrq.gov/node/39392/psn-pdf
September 20, 2011 - of specific system and reminder design features, and
perhaps cultural or contextual features of the institutions
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psnet.ahrq.gov/node/39210/psn-pdf
January 12, 2010 - can-aviation-based-team-training-elicit-sustainable-behavioral-change
As a means of improving safety, many institutions
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psnet.ahrq.gov/node/37808/psn-pdf
February 22, 2011 - This study surveyed inpatients from three different types of institutions to highlight the knowledge,
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psnet.ahrq.gov/node/43969/psn-pdf
November 17, 2017 - when things go wrong: physician attitudes
about reporting medical errors to patients, peers, and
institutions